Wednesday, March 30, 2016

Do medical students have drinking problems?

A study from the Mayo Clinic says one-third of US medical students drink too much alcohol and something must be done about it.

In 2012, the authors sent a survey with questions about alcohol abuse, burnout, depression, fatigue, suicidal ideation, and quality of life to 12,500 medical students of whom 4402 (35.2%) responded.

Of those responding, 1411 (32.4%) “met diagnostic criteria for alcohol abuse/dependence.”

According to the Mayo Clinic’s press release, “Nationally, that translates to about one-third of those responding, compared to only 16 percent of peers not in medical school, and double the rate of alcohol abuse or dependence of surgeons, US physicians or the general public based on earlier research by this team.”

The paper also found that burn out, depression, high educational debt, being unmarried, and being younger were associated with dependence on or abuse of alcohol.

The authors called for a multifaceted approach “addressing burnout, medical education costs, and alcohol use.”

Here are some problems with this study.

Thursday, March 24, 2016

Less crowded EDs = less waiting & "big data" isn't so big

Two recent papers caught my eye. As usual, I will preface my critiques with a disclaimer that I have never written a Nobel Prize-winning paper myself.

The first paper, “Emergency department ‘undercrowding’ is associated with decreased waiting times” appeared online in the journal Emergency Medicine Australasia.

The authors looked at emergency department patient numbers and waiting times before and after a nearby tertiary care hospital opened a new emergency department.

Their main finding was that after the new ED opened, their ED saw 28% fewer patients with a concomitant decrease in patient waiting times of 15 minutes from 26 to 11 minutes with p < 0.001, a significant difference.

They concluded, “Wait times are strongly associated with patient presentation numbers.” Furthermore, “Controlling demand may benefit patient processing, flow, and patient perceptions of level of care.”

Wednesday, March 16, 2016

Why hospital rankings are bogus

At the end of 2015, The Leapfrog Group announced its annual list of America’s top hospitals for quality and safety; 98 hospitals receiving the honor.

Unlike some other hospital rating schemes, Leapfrog’s does not factor in reputation. You won’t find any of the usual suspects on Leapfrog’s list. Instead, Leapfrog uses surveys of hospitals and publicly available quality and safety data.

Leapfrog’s top 98 included 62 urban, 24 rural, and 12 children’s hospitals. Of the 86 urban and rural hospitals, only three were university hospitals—University of California Davis Medical Center, University of California Irvine Medical Center, and University of Tennessee Medical Center.

New York managed to place only one hospital on the Leapfrog list.

Other interesting anomalies are that for several states such as Connecticut, Indiana, and Maryland, no hospitals made the list, and of the 21 California hospitals that did, 17 are Kaiser-affiliated. Looks like Kaiser knows how to play the game.

Friday, March 11, 2016

Ethics and uterus transplants

Guest post by @UtilityKnife1

It’s easy to be negative. Given that the return in clinical outcomes relative to cost is too often poor for any clinical innovation (e.g., robotic surgery, home uterine monitoring, bone marrow transplants for breast cancer, etc.), it is a reasonable bet anything new in medicine is lemon. Innovation and technology within health care account for significant portions of per capita growth in health spending among Americans over the last 50 years. In some cases this spending has resulted in real improvements in health outcomes but this is not the case in many settings. So what about spending to transplant a uterus?

Uterine transplant is not new. The procedure has been done in animals, has even resulted in live births among humans, and is not conceptually complicated. A donor uterus including the cervix is sutured to the top of the vagina, and the blood supply is hooked up. Since there is no nervous input into the transplant, it will not contract in any sort of coordinated way and delivery of any fetus must be via cesarean section. Similarly, fetal movements will not be felt in the same way. Any “experience” of pregnancy from a transplanted uterus is thus not totally natural (note the recent patient who underwent uterus transplantation at The Cleveland Clinic said “experiencing” pregnancy was an important reason behind her decision to pursue this surgery).

The reason to perform a uterine transplant is most easy to understand in those settings where a woman is born without a uterus (although in these cases they should have ovaries). Getting pregnant with a transplanted uterus requires in vitro fertilization. The organ recipient will have to take anti-rejection drugs, and when pregnancy is no longer desired, the uterus should be removed to avoid prolonged exposure to these drugs. None of this is an ordinary part of the pregnancy experience to say nothing of the implications for the fetus.

Tuesday, March 8, 2016

An intraoperative leak test should not be done; or should it?

Here is an abstract recently published ahead of print in the American Journal of Surgery. Please read it because a one-question test follows.

Introduction: Staple line leak after sleeve gastrectomy (SG) is a rare but dreaded complication with a reported incidence of 0-8%. Many surgeons routinely test the staple line with an intraoperative leak test, but there is little evidence to validate this practice. In fact, there is a theoretical concern that the leak test may weaken the staple line and increase the risk of a postop leak.

Methods: Retrospective review of all SG performed over a 7-year period. Cases were grouped by whether an intraoperative leak test (IOLT) was performed, and compared for the incidence of postop staple line leaks. The ability of the IOLT for identifying a staple line defect and for predicting a postoperative leak was analyzed.

Results: 542 SG were performed between 2007-2014. 13 patients (2.4%) developed a postop staple line leak. The majority of patients (N=494, 91%) received an IOLT, including all 13 patients (100%) who developed a subsequent clinical leak. There were no (0%) positive IOLTs and no additional interventions were performed based on the IOLT. The IOLT sensitivity and positive predictive value were both 0%. There was a trend, although not significant, to increased leak rates when a routine IOLT was performed versus no routine IOLT (2.6% vs. 0%, p=0.6).

Conclusions: The performance of routine IOLT after sleeve gastrectomy provided no actionable information, and was negative in all patients who developed a postoperative leak. The routine use of an IOLT did not reduce the incidence of postop leak, and in fact was associated with a higher leak rate after SG.

Do you agree with the authors that the routine use of the IOLT was associated with a higher leak rate after sleeve gastrectomy?

Friday, March 4, 2016

Are today’s surgery residents poorly trained? What can be done about it?

A surgical resident writes

I’m sure you have read several recent studies suggesting that current general surgery residents are poorly trained and unprepared for independent practice at the completion of residency.

My questions for you:

1. In general, do you agree that current general surgery residents are poorly trained and unable to operate independently at the completion of residency?

2. What should we do differently? I personally don’t feel that “more simulation activities”, which many have suggested, is an adequate solution.

Thank you for the excellent questions.

I have been out of the surgical education loop for a few years and no longer have first-hand experience, but the literature does indicate that some surgical residency graduates are not ready to practice by themselves.